Medical Record Note

Scores are listed in the left column.

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Cancer/Lymphoma Case Study
A
(3 pts)

Pts mother states that Ms. Mitchells mouth hurts so badly that she can hardly
talk. She has had only pured foods, vegetable juices, and a little water over the
last 3 days.
Pts mother states that the patients aunt and uncle introduced them to a special
anti-cancer diet
Pt was told to only eat natural foods without any meat or dairy products. She is
on 5000 mg of vitamin C, 20,000 mg RE of vitamin A, and 1000 mg vitamin E.
Pt is also taking a mixture of echinacea, ginger, and ginseng.

D
Dx:
____points
Dx:
____points

A
(Each
PES
statement
is worth
4 points)

Dx:
____points

21 YO Female
Ht: 66
Wt: 108 #
BMI: 17.4
IBW: 130 lbs
IBW%: 83%
Temp 102.5F, BP 95/70 mmHg, HR 90 bpm, RR 22 bpm
TEE: 2,012.7
WBC: 12 x 103/mm3
HGB: 11 L
HCT: 31 L
MCV: 70 L
MCHC: 27 L
Biting/Chewing (Masticatory) Difficulty (NC-2.1) related to oral manifestations
of a systemic disease as evidenced by oral sores interfering with eating ability,
inadequate energy intake based off 24-hour food recall, and pt. statement of
severe mouth pain.
Inadequate protein-energy intake NI-5.2 related to decreased ability to consume
sufficient protein and/or energy as evidenced by 24-hour food recall, poor
appetite, nausea, vomiting and pt. statement on painful candidiasis fungal
infection of the mouth making it difficult to talk and eat.
Underweight NC-3.1 related to inadequate energy intake and disordered eating
patterns as evidence by 24-hour food recall, pt. statement on painful mouth sores
increasing eating disability and a BMI of 17.5.

I (M/E)
I:
____points
M/E:
____points

Increase energy diet (ND-1.2.2.1) recommended 35 kcal to increase weight gain.

Intervention: 6.5
pts

Increased protein diet (ND-1.2.3.1) recommended to 1.2 g/kg to promote wound

healing and to help bone marrow produce additional red blood cells

M/E;
2.5 pts)

Commercial beverage (ND-3.1.1) recommended to help supplement patients

calorie needs.
Pureed Diet ND-1.2.1.3 until mouth health improves, eliminate sore irritants

Mouth care (ND -4.4) via nystatin swish and swallow

Nutrition education on nutrition relationship to disease (E-1.4) to ensure patient

understands r3eason for increased energy, protein, and beverage intake.
Collaboration and Referral of Nutrition Care (RC-1) hold a team meeting to
develop a comprehensive plan of care and consider implementing enteral
nutrition due to patients difficulty eating and functional GI tract.
Goal setting (C-2.2) should be used to assist client in gaining knowledge in
nutritional counseling strategies.
Monitor and evaluate total energy intake (F.H.-1.1.1.1) to ensure patient is
meeting increased energy needs.
Monitor patient weight (A.D-1.1) to ensure no further weight loss and track and
weight gain.
Coordinate care with patients physician and oncology team
Signature- 1pt

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Ashley Konich
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